Embassy of Italy Accra Ambassade d`Italie Accra

Embassy of Italy Accra
Ambassade d’Italie Accra
PHOTO
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Application for National Visa (D) - This application form is free
Demande de Visa National (D) – Ce formulaire est gratuit
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1. Surname / / Nom(s) [nom(s) de famille]
...........................................
Spazio riservato
all'amministrazione
2. Surname at birth (Former family name(s) / Nom(s) de naissance [nom(s) del famille antérieur(s)]
3. First name(s) Given name(s) / Prénom(s)
Data della domanda:
4. Date of birth (day-month-year)
Date de naissance (jour-mois année)
5. Place of birth / Lieu de naissance
7. Current nationality
Nationalité actuelle
6. Country of birth
Pays de naissance
8. Sex / Sexe
Nationality at birth, if different
Nationalité à la naissance, si différente
9. Marital status / Etat civil
Single / Célibataire
Married /Marié(e)
Separated / Séparé(e)
Divorced / Divorcé(e)
Widow(er) / Veuf (veuve)
Other (please specify) / Autre (veuillez préciser)
Male / Masculin
Female / Féminin
Numero della domanda di
visto:
Domanda presentata presso:
Ambasciata/Consolato
Centro comune
Fornitore di servizi
Intermediario commerciale
Altro
Nome:
10. In the case of minor: Surname, first name, address (if different from applicant’s) and nationality of parental authority/
legal guardian/ / Pour les mineurs: Nom, prénom, adresse (si différente de celle du demandeur) et nationalité de l’autorité parentale
/ du tuteur légal
Responsabile della pratica:
11. National identity number, where applicable / Numéro national d’identité, le case échéant
Nome di chi ha ricevuto la
pratica allo sportello:
12. Type of travel document / Type de document de voyage
Ordinary passport / Passeport ordinaire
Diplomatic passport / Passeport diplomatique
Service passport / Passeport de service
Official passport / Passeport officiel
Special passport / Passeport spécial
Other travel document (please specify) / Autre document de voyage (à préciser)
13. Number of travel document / 14. Date of issue.
Numéro du document de voyage
Date de délivrance
15. Valid until
Date d’expiration
17. Applicant’s home address and e-mail address
Adresse du domicile et adresse électronique du demandeur
16. Issued by/ Délivré par
Telephone number(s)
Numéro(s) de téléphone
Documenti giustificativi:
Documento di viaggio
Mezzi di sussistenza
Invito
Mezzi di trasporto
Assicurazione sanitaria di
viaggio
Altro
Decisione relativa al visto:
18. Residence in a country other than the country of current nationality
No/ /Non
Résidence dans un pays autre que celui de la nationalité actuelle
Yes / /Oui
Residence permit or equivalent………………….. n./…………………………… Valid until/………………
Autorisation de séjour ou équivalent n. ………………..
Date d’expiration …………………………….
19. Current occupation / Profession actuelle
20. Employer and employer’s address and telephone number. For students, name and address of educational
establishment / Nom, adresse et numéro de téléphone de l’employeur. Pour les étudiants, adresse de l’établissement d’enseignement
21. Main purpose(s) of the journey / Objet(s) principal(aux) du voyage
Rifiutato
Rifiutato per segnalazione
SIS non cancellabile.
Pratica Sospesa
Rilasciato
Tipo di visto:
D
Valido:
dal …………………………..
al…………………………….
Family rejoining/Accompanying spouse
Religious purpose(s)............
Medical reasons. .............
Self employment
Sport/........
Mission....................................
Diplomatic
Study/.................
Adoption
Employment
Other (please specify)/.....................................…………………………….
Numero di ingressi:
1
2
Multipli
(x) Fields 1 to 3 must be filled with information as indicate on the travelling document (field 12).
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22. Member State(s) of destination
...........................................
23. Member State of first entry
..........................................
24. Number of entry requested/ ...............................:
25. Duration of the intended stay. Indicate the
number of days (max 365 days) /
.......................................................:
Si ng le en try / .. . ...
Tw o e ntr i es /. .. .. .
Multiple entries/.............
26. Schengen visa issued during the past three years / ......................... ........................:
N o / .. .
Yes. Date(s) of validity …………. from/....…………………………….. to /.. ………………………………. …
27. Fingerprints collected previously for the purpose of applying for a Schengen Visa
................................................ .................... . . .............................................:
No/...
Yes/.... Date, if know/......................
…………………………………………………………………………….……
28. Number of ”Nullaosta” issuded for Family reunion/ Accompanying spouse and/or family/ Employment (only if
request by the corresponding legislation)/ ...........................................................
Issued by SUI of /.......................................... ………………………………………….
29. Intended date of arrival in the Schengen area
......................................................................
30. Intended date of departure from the Schengen area
(only for visas with validity between 91 and 364 days).
..........................................................
31. Surname and first name of the inviting person which applied for the Family reunion or employer. In case of
adoption, Religious purpose(s), Medical reason(s), Sport, Study, Mission: address of temporary residence in Italy.
...................................................................... .................................... .......... ......................................... .
Address and e-mail address of the person(s) which applied
for family reunion or employer
................................................................................
Telephone and fax number of the person(s) which
applied for Family reunion or
employer...............................................
32. Name and address of the inviting
Company/organization /.......................................................
Telephone and fax number of the inviting
Company/organization
.................................................................
Surname, name, address, telephone, fax and e-mail address of the contact person of the inviting
Company/organization .......................................................................................................................................................
33. Cost of travelling and living during the applicant’s stay is covered ………
/.......................................................................:
by the applicant himself/herself.........................................
by a sponsor (host, company, organization),
please specify/ ........................................................
:…………………………………………….
Means of support/..........................................:
Referred to in field 31 or 32/ .......................
Cash/ ..............................
Traveller's cheque/................................
Credit card/..................................
Prepaid accommodation/..........................
Prepaid transport/...............................
Other (specify)/....................:..................................
SHALL NOT BE FILLED IN BY APPLICANTS FOR:
Family reunion, Accompanying spouse and/or family,
Employment/Self employed, Mission, Diplomatic, Adoption.
Other (specify)/..........................:…………………
Means of support/..............................:
Cash/....................
Accommodation provided/................................
All expenses covered during the stay/
....................................................
Prepaid transport/.....................
Other (please specify)/ ..................………………..
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34. Personal data of the family member who is an EU, EEA or CH citizen .........................................................................
Surname / ................
First name(s) / ......................
Date of birth / ....................
Nationality / .......................
Number of travel document or ID card
..............................................
35. Family relationship with an EU, EEA or CH citizen/ ........................................................................:
spouse/................
grandchild/............
son/daughter / ........./..
dependant ascendant/.............................
36. Place and date / ................................
37. Signature (for minor, signature of parental
authority/legal guardian)/ .....................................................
I am aware that the visa fee is not refunded if the visa is refused:
........................................................................... ...........................................................................................
I am aware of and consent to the following: the collection of the data required by this application form and the taking of my photograph and, if
applicable, the taking of fingerprints, are mandatory for the examination of the visa application; and any personal data concerning me which
appear on the visa application form, as well as my fingerprints and my photograph will be supplied to the relevant Italian authorities and
processed by those authorities, for the purpose of a decision on my visa application.
Such data as well as data concerning the decision taken on my application or a decision whether to annul or revoke a visa issued will be entered
into, and stored in the Consular Section of the Italian Embassy and the Ministry of Foreign Affairs. Such data will be accessible to the National
authorities competent for Visas. Furthermore the data will be accessible to the Schengen authorities competent for carrying out checks on visas at
external borders and to the competent authority of the Member State for immigration and asylum (for the purposes of verifying whether the
conditions for the legal entry into, stay and residence on the territory of the Member State are fulfilled, of identifying person who do not or who no
longer fulfil these conditions), to the competent authority of a Member State to examining an asylum application. Under certain conditions, the
data will be also available to designated authorities of the Member States and to Europol for the purpose of the prevention, detection and
investigation of terrorist offences and of other serious criminal offences.
I am aware that I have the right to obtain the notification of the data relating to me recordered in the informatic system and to request that the
data relating to me which are inaccurate be corrected and that the data relating to me processed unlawfully be deleted. At my express request, the
authority examining my application will inform me of the manner in which I may exercise my right to check the personal data concerning me and
have them corrected or deleted, including the relate remedies according to the national law.
The national supervisory authority is the “Garante per la protezione dei Dati Personali”.
I declare that to the best of my knowledge all particulars supplied by me are correct and complete. I am aware that any false statements will lead to
my application being rejected or to the annulment of a visa already granted and may also render me liable to prosecution from The Italian
Consulate under the law of the State (Article 331 c.p.p.).
The mere fact that a visa has been granted to me does not mean that I will be entitled to compensation if I fail to comply with the relevant provision
of Article 5, paragraph 1 of the Regulation (UE) No 562/2006 (Schengen Borders Code) and the article 4 of D.Lgs No.286/98 and I am therefore
refused entry.
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NOTE (
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for official use only)
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Place and date / ....................... Telephone numbers……………………
Signature (for minors, signature of parental authority / legal guardian) /
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